Worcester, MA Area)

CareSource Management Services•Worcester, MA

6d•Hybrid

About The Position

Commonwealth Care Alliance’s Care Delivery program provides care delivery and care management to a panel of high-risk people with complex needs. The Community Health Worker (CHW) is an integral member of an interdisciplinary team supporting care delivery and coordination for patients with complex medical and behavioral health needs. The CHW helps patients address social determinants of health as part of individualized, patient-centered care plans, using community-based resources, trauma- and recovery-informed skills, and health coaching and education to support better outcomes, reduce gaps in care, and connect patients with community services and long-term supports. The role focuses on preventive care, engagement with primary care, behavioral health and substance-use services, and supporting patients with frequent emergency department visits or acute admissions. The CHW works to identify social factors affecting care and partner with patients on appropriate supports. The position reports to a Care Delivery Clinical Manager. It involves telephonic, virtual, and in-person outreach, including home visits, and routine travel to patients and CCA sites. More than 50% of the role is mobile. Services are delivered in patients’ homes, and the role is described as non-clinical. The position requires in-person contact with CCA members or patients. The CHW documents services and follow-ups, collaborates with patients, providers, and internal interdisciplinary teams, and participates in team meetings, quality improvement, training, and clinical program development. The role requires a valid driver’s license, vehicle, and verifiable insurance, with employment conditional on acceptable driver’s license and criminal background checks. Annual influenza vaccination is required for designated positions during influenza season, subject to the stated timing requirements. Compensation is hourly, with a stated range of $41,200 to $66,000; a performance-based bonus may also be available.

Requirements

Associate degree required; equivalent years of relevant work experience may be accepted in lieu of the required education.
Three or more years of experience in community-based care required.
Five or more years of experience in outreach or community work with patients who have high behavioral health needs and high medical complexity.
Excellent written and verbal communication skills.
Working knowledge of Microsoft Office applications; demonstrated proficiency with Excel, Word, and Outlook.
Strong organizational, time-management, and problem-solving skills.
Ability to use an electronic medical record and online training platforms.
Demonstrated understanding of Mass Health benefits and long-term services and supports (LTSS).
Ability to review welcome packets and obtain consent forms.
Judgment and skills for independent decision-making and ability to function effectively on a multidisciplinary team.
Strong interpersonal and customer-relations skills.
Comfort working with durable medical equipment vendors and verifying product accuracy and quotes.
Willingness to learn and use telehealth technologies, including video and chat, when appropriate.
Valid driver’s license, vehicle, and verifiable insurance; employment is conditional on acceptable driver’s license record check.
Annual influenza vaccination is required for designated positions during influenza season, subject to the stated timing requirements.
Employment is conditional on successful clearance of a criminal background check.

Nice To Haves

Bachelor’s degree preferred.
Experience with an electronic medical record, with eCW specifically preferred.
Community Health Worker certification preferred.
Housing Specialist certification preferred.
Certified Application Counselor (CAC) preferred.
Certified Addiction Recovery Coach (CARC) preferred.
Health or Wellness Coach certification preferred.

Responsibilities

Deliver care management and care coordination support to complex patients and collaborate with external providers to support comprehensive care.
Regularly assess patients’ social determinants of health and identify barriers to care or unmet needs.
Conduct scheduled outreach and visits by phone, virtually, or in person, and provide urgent follow-up for significant medical or behavioral health social needs.
Coach and educate patients to promote wellness, prevent or reduce health risks, and support chronic disease self-management and healthy behaviors.
Support patient health education in coordination with the interprofessional care team and primary care provider.
Collaborate with patients on social-determinant-of-health goals in their care plans and provide support and education on care management and coordination decisions.
Coordinate closed-loop communication with external providers and the CCA interprofessional team to identify resources and implement care plans.
Support efforts to reduce hospital admissions, readmissions, and emergency department use.
Support patient retention and connection to Medicaid and Medicare benefits.
Educate patients about quality measures, preventive health maintenance, and routine medical screenings.
Assist patients with housing, finances, food, utilities, education and vocational opportunities, and community supports.
Build relationships with community agencies and service providers to support patients.
Address substance misuse or abuse, when indicated, with behavioral health clinicians and supports.
Use motivational interviewing, harm reduction, positive behavioral support, limit setting, and strengths-based approaches to help patients attain their goals.
Coach patients in technology use and provide one-to-one support during virtual visits with licensed clinicians when needed.
Document visits clearly and comprehensively in English, complete tasks within required timelines, follow organizational policies, and maintain confidentiality.
Communicate follow-up plans to the interdisciplinary care team and provide input on care management and coordination decisions.
Identify and initiate plans to address opportunities for meeting key performance indicators.
Collaborate with primary care providers and other external providers, including specialty services, LTSS coordinators, Aging Service Access Points, visiting nurse services, care attendants, and patient-designated contacts or next of kin.
Communicate and collaborate with internal interdisciplinary colleagues, including health plan care teams, clinicians, medical directors, palliative care and psychiatric services, rehabilitation, crisis response, patient services, administrative staff, and CCA leaders.
Participate in weekly interprofessional care team meetings and ad hoc case conferences, and provide consultation and support to other CCA Care Team patients.
Participate in ongoing education and training, CCA quality improvement, program and workflow development, and committees or workgroups promoting clinical excellence and CCA’s mission and business objectives.
Deliver clinically appropriate care management services to patients through telehealth technologies such as video and chat.
Perform other job-related duties as assigned.